Those who were working in medicine in the 1980s remember the time well. Patients — especially, and most strikingly, young and otherwise healthy men — began appearing in doctor’s offices and emergency rooms with rare infections. At first, this seemed like a series of strange medical coincidences. Soon, however, it became apparent that something had sabotaged their immune systems.

At first, no obvious cause of this apparent immunodeficiency presented itself. Still, the strange infections would crash over the affected patients like relentless waves, and then, finally, the patients would begin to waste away. Over years, the patients would grow cachectic and eventually languish in bedrooms or in the bays of hospitals — this phantom disease erasing their bodies day by day, until it finally claimed their lives.

Equally tragic, these patients soon became like modern lepers, especially if friends and family feared contracting the virus themselves. Then, when HIV came to be associated with men who had sex with men, stigma was heaped atop their physical ailments, and many of them died not only mysteriously, but also as outcasts from their family and friends.

Out of the ashes of this tragedy arose one of the miracles of modern medicine. Thanks to the work of patient advocates, patients themselves and intrepid researchers, the landscape of HIV and AIDS has transformed dramatically in the last 45 years. Now, highly active antiretroviral treatment has made HIV a manageable chronic illness for many people. Indeed, in 2025, if a patient is newly diagnosed with HIV in the United States, he or she should be able to keep the disease under good control unless the patient does not have access to consistent and appropriate medical care.

Sixteen-year-old Idah Musimbi, who contracted HIV at birth and lives with her grandparents and cousins in Nairobi's Kawangware slum, takes her PEPFAR-supplied anti-retrovirals pills Wednesday, Aug. 16, 2023. A U.S. foreign aid program that officials say has saved 25 million lives in Africa and elsewhere is being threatened by some Republicans who fear program funding might go to organizations that promote abortion. | Brian Inganga

Sadly, however, not all countries find themselves blessed with the same healthcare infrastructure or access to resources as the United States. Consequently, there are many places in the world where the ability to treat and control HIV has lagged significantly. Highly active antiretroviral treatment, also known as HAART, is not like a course of antibiotics that can be taken for pneumonia in just a week. Because we have not yet developed treatments that will entirely eradicate the HIV virus in most cases, patients have to take suppressive medications on a carefully designated schedule, usually for the rest of their lives. Consequently, delivering effective treatment to patients in countries with less access to resources than what we have in the United States initially posed significant logistical and financial problems.

Thus it was that, in 2003, with the guidance of public health professionals, President George W. Bush established PEPFAR, or the “President’s Emergency Plan for Aids Relief.” Over the past 20 years, this fund and its accompanying infrastructure have helped to provide access to effective HIV care in countries that would otherwise lack it. Thanks to this program, tens of millions of individuals in resource-poor settings have received access to medications that they otherwise would be without. It is impossible to know the entire scope of the impact of this program, but reasonable estimates calculate that it has likely saved about 25 million lives.

Related
Why George W. Bush believes AIDS relief program is in danger

I fear, however, that such statistics are so impressive as to blunt our understanding of the individual impact these medications have. Twenty-five million after all, is just a number, but these medications save individual lives. I met many patients with HIV when I worked for a month in a clinic in South Africa in 2011 that treated those with HIV, tuberculosis, or both. The message I gleaned from that short experience is simply this: The people receiving these medications in far flung places are every bit like you and me — fathers, mothers, brothers, sisters, friends and family members hoping to chase their dreams and go about their lives.

Bernard Mwololo feeds chickens at the Nyumbani Children's Home in Nairobi, Kenya, Tuesday, Aug. 15, 2023. Benard has lived most of his life at the orphanage after his parents died of AIDS, he's now an HIV activist and believes he is only alive because of the antiretroviral drugs that PEPFAR supplies. A U.S. foreign aid program that officials say has saved 25 million lives in Africa and elsewhere is being threatened by some Republicans who fear program funding might go to organizations that promote abortion.

Indeed, working at that clinic during that month reminded me of nothing so much as Shylock’s famous soliloquy from “The Merchant of Venice”: “I am a Jew. Hath not a Jew eyes? Hath not a Jew hands, organs, dimensions, senses, affections, passions? Fed with the same food, hurt with the same weapons, subject to the same diseases, healed by the same means, warmed and cooled by the same winter and summer, as a Christian is?”

It is a haunting truth to recognize that, in terms of access to treatment for HIV, there are still too many places in the world where young and otherwise healthy people with immune systems ravaged by the virus waste away into cachexia and death. The difference this time, however, is that effective treatments exist — it is simply that the patients are denied access them. PEPFAR was meant to change that — to bring healing and hope to those who otherwise would be without it.

All of this has been on my mind because we are in the midst of a national reckoning with respect to the way in which our nation engages with others around the world. Such questions have always been at the heart of complex discussions involving the role of the United States on the world stage — from George Washington admonishing us not to entrap ourselves in “foreign entanglements,” to our entry into two World Wars, to the most recent withdrawal of troops from Afghanistan. Such questions will always be complex, and I do not pretend to have easy answers. Every dollar of federal money spent anywhere is a dollar that cannot be spent elsewhere, and heaven knows myriad pressing problems confront us here at home, even as we confront the nation’s $36 trillion debt.

Children play at the Nyumbani Children's Home in Nairobi, Kenya, Tuesday, Aug. 15, 2023. The orphanage, which is heavily reliant on foreign donations, cares for over 100 children with HIV whose parents died of the disease and provides them with housing, care, and PEPFAR supplied antiretroviral drugs. A U.S. foreign aid program that officials say has saved 25 million lives in Africa and elsewhere is being threatened by some Republicans who fear program funding might go to organizations that promote abortion.
85
Comments

Yet, even when recognizing all of this complexity, I cannot help but think that PEPFAR and programs like it represent the best of us. The United States, after all, represents perhaps the best resourced nation-state in the history of the world, and, as members of a global community, I believe we must take seriously that which we can do to aid where we can, especially in places where we have already made deep commitments.

The new administration seems to realize this, having granted a waiver that allows PEPFAR to continue throughout the 90-day pause in foreign aid that President Donald Trump ordered. But for the sake of continuity and to protect the patients of future years, it’s important that this work continue beyond the next three months.

I hope all of us will make clear to our governmental representatives that the funding and functioning of programs such as PEPFAR matter deeply. While money will always be scarce, and debates will always abound, I believe these causes remain worthy of precious resources— and always will.

Dr. Tyler Johnson is co-host of the podcast “The Doctor’s Art,” a clinical associate professor of medicine at Stanford School of Medicine and a director of the Stanford Oncology Fellowship Program.

Join the Conversation
Looking for comments?
Find comments in their new home! Click the buttons at the top or within the article to view them — or use the button below for quick access.